Transcript Rheumatoid Arthritis

Rheumatoid Arthritis
Dr ahad azami
Rheumatoid Arthritis
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Systemic
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Chronic
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Inflammatory
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Primarily targets the synovium of diarthrodial joints
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Etiology likely combination genetic and
environmental
Diarthrodial Joint
Rheumatoid Arthritis
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Female: male 3:1
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4th-6th decades of life
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Symmetric polyarthritis
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Extra-articular manifestations
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Subcutaneous nodules/lung nodules
Scleritis
Vasculitis
Felty’s syndrome
Stages of RA Pathogenesis
Stage
Symptoms
Findings
1.
Antigen
Presentation
to T Cells
None
None
Normal X-ray
2.
T and B Cell
Proliferation,
Angiogenesis
in Synovium
Malaise, Mild,
Joint Stiffness
Swelling
Swelling or Pain
of Small Joints
Wrists, Knees
Normal, X-ray
ACR
Stages of RA Pathogenesis (Continued)
3.
Stage
Symptoms
Findings
SFPMN
Accumulation
Synovial Cell
Proliferation
Joint Pain,
Swelling
AM Stiffness,
Malaise,
Weakness
Warm, Swollen
Joints, Inc SF
Soft Tissue
Proliferation,
Limited ROM,
Nodules, Soft
Tissue Swelling
on X-ray
ACR
Stages of RA Pathogenesis (continued)
4.
Stage
Symptoms
Findings
Pannus
Invasion,
Chondrocyte
Activation,
Enzyme
Activation
Same as
Stage 3
Same as
Stage 3
Periarticular
Osteopenia,
Proliferative
Pannus on MRI
ACR
Stages of RA Pathogenesis (continued)
Stage
5.
Subchondral
Bone Erosion,
Pannus
Invasion of
Cartilage
Stretched
Ligaments
Symptoms
Findings
Same as
Stage 3
Plus Loss
of Function
Deformity
Same as stage 3
Plus Instability
Flexion
Contractures,
Extra-Articular
Disease, Early
Erosions and Joint
Space Narrowing
on X-Ray
ACR
Synovium in RA
PIP Swelling
Ulnar Deviation, MCP Swelling,
Left Wrist Swelling
Joints involved in RA
Joints involved in RA
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Don’t forget the cervical spine!! Instability
there can lead to impingement of the spinal
cord
Thoracolumbar, sacroiliac, and distal
interphalangeal joints of the hand are not
involved
Extra-articular Symptoms
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Patients that are more likely to get are:
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RF+
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HLA DR4+
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Male
Corneal Melt
Nodules
Pulmonary Nodules
Felty’s Syndrome
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Seropositive Rheumatoid Arthritis
Splenomegaly
Granulocytopenia
ACR
Large Granular Lymphocytes
Labs
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Can also see nonspecific abnormalities
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High sedimentation rate
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Anemia
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Hypergammaglobulinemia
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Thrombocytosis
Rheumatoid Factor
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Antibodies that recognize Fc portion of
IgG
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Can be IgM, IgG, IgA, IgE
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85% of patients with RA over the first 2
years become RF+
Anti-ccp
Radiographic Features
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Peri-articular osteoporosis
Uniform joint space narrowing
Marginal erosions
Soft tissue swelling
Subluxations
Symmetric
Cysts
Synovial Fluid
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Inflammatory
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WBCs 5000-50,000
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≥ 50% neutrophils
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No crystals
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Negative Cultures
Noninflammatory on left
Inflammatory on right
ACR Criteria
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Morning Stiffness ≥1 hour
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Soft tissue swelling of ≥ 3 joints observed by
physician
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Swelling of proximal interphalangeal (PIP),
metacarpophalangeal (MCP), or wrist joints
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These signs and symptoms must be present ≥ 6 weeks
ACR Criteria Continued
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Symmetric Arthritis present for ≥ 6 weeks
Subcutaneous nodules
Positive Rheumatoid Factor
Radiographic Erosions or periarticular
osteopenia in hand or wrist joints
Must have ≥4 criteria to meet diagnosis of RA
Criteria for Progression of RA
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Stage I – Early
No Destructive Changes
Osteoporosis on X-Ray
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Stage II – Moderate
Osteoporosis and Slight Subchondral Bone or
Cartilage Destruction
No Joint Deformaties, Mobility May be Limited
Adjacent Muscle Atrophy
Nodules or Tenosynovitis May be Present
ACR
Criteria for Progression of RA
(continued)
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Stage III – Severe
Osteoporosis and Erosions
Deformity Without Ankylosis
Extensive Muscle Atrophy
Nodules and Tenosynovitis
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Stage IV – Terminal
Fibrous or Bony Ankylosis
Features of Stage III
ACR
Management
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Focused on relieving pain and preventing
damage/disability
Patient education about the disease is key
Physical Therapy for stretching and range of motion
exercises
Occupational Therapy for splints and adaptive
devices
Surgery
Rheumatoid Arthritis:
Classification of Function
Class I:
No Limitations
Class II:
Adequate for Normal Activities Despite
Joint Discomfort of Limitation of Movement
Class III:
Inadequate for Most Self-Care and
Occupational Activities
Class IV:
Largely or Wholly Unable to Manage SelfCare; Restricted to Bed or Chair
ACR
Medicines
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Non-Steroidal anti-inflammatories (NSAIDS)
for symptom control
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Prednisone for quick control of joint
inflammation but cannot use long term due to
side effects
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Osteoporosis, cataracts, weight gain, insulin
resistance, dyslipidemias
Disease Modifying Antirheumatic Agents
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Drugs that actually control the disease and not
just treat symptoms
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Should be used early on in patients
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Erosions can develop in the joints of patients
within the first two years of disease
Disease Modifying Antirheumatic Agents
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Hydroxychloroquine-for mild disease, takes a
long time to reach steady state, very benign in
side effect profile
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Sulfasalazine-for mild disease, toxicities
include GI upset
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Azathioprine-for moderate disease, not as
modifying as other drugs, cytopenias
Disease Modifying Antirheumatic Agents
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Methotrexate-moderate to severe disease, very
successful in preventing erosions, liver
toxicities
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Anti-TNFα agents-used for mod-severe
disease, but moving up as first line drug, TB
reactivation a concern
Prognosis
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RA can shorten the life span 3-18 years
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Most die from cardiovascular disease, infection or
lymphoproliferative disorders
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Overall RA patients are much better off than at any
other time in history due to ongoing research and new
meds!!